Sleep as a Medication in Epilepsy

Danilo Vitorovic, MD, is a neurologist at The University of Vermont Medical Center and an associate professor at the Larner College of Medicine at UVM.

Living with epilepsy can be a challenging experience, mostly due to the unpredictable timing of the next “event.” An event may disrupt a work routine, prevent one from driving, or inflict serious injury. The patient, their loved ones, and their physicians try to do everything to prevent that next “event” – the breakthrough seizure.

Medical terms in epilepsy made simple

Before we go further, we should clarify the terms epilepsy and epileptic seizures.

Epilepsy is a disorder of the brain in which electrical stability of nerve cells is disturbed, resulting in the propensity toward recurrent spontaneous onset seizures. In many instances this is a chronic disorder that as of yet we have no definite cure.

An epileptic seizure is an event characterized by abnormal electrical activity in the brain and associated changes. Most frequently, we see changes in awareness and rhythmic limb movements, noted by the patient and/or people witnessing the seizure.

It is important to note that being diagnosed with epilepsy does not necessarily mean that a person will continue to have epileptic seizures. The goal of medical therapy and lifestyle modifications is to decrease the likelihood of recurrent (or “breakthrough”) epileptic seizures as much as possible. Goals for epilepsy control, optimization of medical therapy, and potential surgical therapy should be discussed with your physician at the time of an office visit.

Here, we will discuss one important factor in the equation of recurrent seizures: sleep.

Sleep 101

Sleep. We spend around a third of our lives sleeping, but we do not fully understand it.

We frequently consider it a waste of time, and we find excuses to avoid it. When the day gets busy and your schedule swells, sleep is the first to slip off our usual routine. That is how it should be, right? There is so much to do, so much to see, and so much to experience that “wasting” a third of our lives on the activity when we “don’t do anything” just makes no sense. This is how most of us think. This is how I think. Even if we don’t verbalize it, we make the statement by reading those extra 10 pages at 11 p.m., by completing all 13 episodes of our favorite show in one night, or by holding faithfully to that cup of coffee.

Let us go over some basics of sleep. We all know that sleep is the state when a person is (usually) recumbent, quiet, with eyes closed, and with transient, fully reversible, decreased responsiveness to the surrounding environment. Counterintuitively, the brain is quite active during the process. If we follow electrical activity of the brain using electroencephalography (EEG) we can discern several phases of sleep. After an initial period of drowsiness (non-REM stage I), light sleep ensues (non-REM stage II). This is followed by deep quiet sleep (non-REM stage III) and then the stage of sleep characterized by rapid eye movements (REM sleep). The whole cycle lasts around 90 minutes and repeats itself throughout the night.

Sleep and epilepsy

We frequently forget that sleep is vital for our health. Sleep deprivation is a contributing factor in chronic diseases such as high blood pressure, diabetes, coronary artery disease, and stroke, among others.

Sleep deprivation is also a common provoking factor for breakthrough epileptic seizures. Actually, in many epilepsy types, even with the consistent compliance with the most appropriate antiepileptic medication(s), sleep deprivation will frequently lead to breakthrough seizure. But, there is much more to be said about the intricate relationship between sleep and epilepsy.

It is important to recognize that patients with certain types of epilepsy are more likely to have a seizure during a particular time of a sleep cycle.

Persons with genetic epilepsies, such as juvenile myoclonic epilepsy, are more likely to have breakthrough seizures early in the morning and are quite sensitive to sleep deprivation.

Patients with frontal lobe epilepsies have a significant portion of their seizures during non-REM stages of sleep.

Patients with temporal lobe epilepsies note most of their seizures manifested by confusion and daydreaming during wakefulness (one of the seizure types discussed in the previous blog) but it is more likely that these spells will progress to whole body convulsions during non-REM stages of sleep.

It is interesting to note that electrical changes in the brain highly suggestive of epilepsy that are captured on EEG, called epileptiform discharges, are more likely to occur during non-REM stages of sleep and can be more precisely localized during the REM stage of sleep. This is one of the reasons why your physician might ask you to have a prolonged EEG study – if sleep is captured, potential epileptiform discharges and clinical seizures can be recorded. Capturing these events on EEG (ideally alongside video record of the event) is the basis for accurate diagnosis of epilepsy type. In return, this helps determine the optimal treatment options. These prolonged studies can be done either in the hospital or at home using special EEG devices that record electrical brain activity for several days.

On the other hand, epilepsy itself affects sleep. Persons with epilepsy, especially structural epilepsies such as temporal lobe epilepsy, frequently report excessive daytime sleepiness, poor sleep quality, and insomnia. Breakthrough seizures during the day affect the normal structure of sleep the following night. Even if there are no recent clinically observed seizures, some patients with epilepsy were noted to have decreased sleep efficiency, fragmented sleep, frequent arousals, as well as decreased amount of deep sleep (non-REM stage III) and REM sleep. It is important to note that some older antiepileptic medications might alter the normal structure of sleep, but it is also important to note that patients treated with antiepileptic medications have overall improved sleep quality and see a decrease in excessive daytime sleepiness.

Effects of poor sleep and poorly controlled epilepsy on quality of life

We have learned that poorly controlled epilepsy will impair sleep and that poor sleep will make epilepsy more difficult to control.

The effect of poorly controlled epilepsy with frequent breakthrough seizures and poor sleep will affect a person’s quality of life due to excessive daytime sleepiness, impaired memory, difficulty with concentration, impaired perception, impaired decision making, impaired coordination, more volatile behavior, as well as by paving a basis for chronic diseases mentioned earlier.

It is worth noting that sleep deprivation in completely healthy individuals will cause similar cognitive impairments and increase the risk for chronic cardiovascular and cerebrovascular diseases. It is estimated that around third of motor vehicle accidents caused by loss of awareness are actually due to drivers falling asleep – these accidents frequently result in deaths. It is also reported that some tragic accidents in the past, such as Challenger space-shuttle explosion and Chernobyl nuclear catastrophe, are at least partially caused by impaired decision-making by team members who were severely sleep deprived.

Practical steps to use sleep as a treatment

What should we do with our sleep habits to improve health overall and to better control epilepsy?

First and foremost, there should be enough time allotted to sleep. Most adults need 8 – 8.5 hours of sleep every day to be fully refreshed. Some need more and some need less. It is easy to test where one is on the spectrum – if one does not feel fully refreshed in the morning, the sleep period should be extended the following night – with this procedure repeated until the person wakes up fully refreshed.

Remember that excessive periods of sleeping in order to “make up” for lost sleep is not as effective a strategy as going to sleep at the same time every night (once necessary duration of refreshing sleep is established) and dedicating enough time to sleep.

To make sleep efficient and to avoid difficulties with falling asleep, make sure you have an adequate sleep environment.

The bedroom should be dark and quiet.

One should avoid strenuous physical or mental activity just prior to sleep.

The same applies to any screen exposure – no phones, tablets, or TV while getting ready for sleep, please.

It is helpful to avoid heavy meals 2-3 hours prior to bedtime.

It is essential to avoid any caffeinated drinks during late afternoons or evenings.

Finally, one should try to organize the day in a way that at the end of the day there is a feeling of accomplishment. It is completely counter-productive to attempt to make up for wasted day by working late – one will not be efficient and the following day will be ruined.

In addition, persons with epilepsy should discuss with their physicians the best treatment options so breakthrough seizures and above noted epileptiform discharges are minimized as much as possible.

Yes, it does require discipline. Yes, it is challenging to stick to a preset bed time with business and social demands on one’s schedule. But, if the laws of nature governing our minds and bodies are respected, one will be prized with sharper cognitive abilities, the potential to enjoy more fully every moment of true wakefulness, and decrease the chances of unwanted events, including breakthrough seizures.

Wishing you a good night sleep tonight!

Danilo Vitorovic, MD, is a neurologist at The University of Vermont Medical Center and an associate professor at the Larner College of Medicine at UVM. He has clinical expertise in epilepsy. His goal for his patients is seizure freedom and he is excited to work with them toward that goal.

The University of Vermont Medical Center serves all of Vermont and the northern New York region. Located in Burlington, The UVM Medical Center is a regional, academic healthcare center and teaching hospital in alliance with the University of Vermont